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For a proper public health service

Drafted by Dublin District, CPI, February 2008

At the moment there is such disquiet about the health service that many different people are speaking out against it and offering different solutions. There are those who advocate
  • a dual system, where there is a better public health system and also a private system running alongside it but, unlike the system at the moment, without the private hospitals parasitically using public hospital resources, such as expensive diagnostic, laboratory or radiology equipment or theatres; this is the view of Prof. John Crown, among others;
  • reform of the existing system through radically changing the way the Health Service Executive works and giving priority in allocating funds to different geographical areas, also proposing a different emphasis on types of care, for example more money spent on primary care with the closure of hospitals throughout the country and concentrating on “centres of excellence,” also a reduction in the staff of the HSE administration; these are the views of Orla Hardiman, a consultant neurologist and the co-coordinator of Doctors for a Better Public Health Service;
  • a single health system covered by the state through taxation or a national insurance plan, which would cover all the health needs of the population.
There are also proposals for a reform of the relationship between the HSE and consultants, dentists, opticians, chiropodists, and dieticians.

Our immediate emergency demands

 Stop the building of private hospitals on public hospital land, and end the policy of “co-location.”
 Stop the sale of public hospital land.
 Stop the closure of regional hospitals until a national rationalisation plan based on equitable care for everyone in the country is implemented. So-called “centres of excellence” where the treatment of specific conditions requires specialists and equipment of an exceptional standard should not be used as an excuse for closing county and regional hospitals. These closures should take place only if the hospitals are replaced with multiple local clinics that have facilities for dealing with most of the general problems that now bring patients to general hospitals and for treating acute heart and stroke patients as quickly as possible, with the same referral rights and charges as for public hospitals.
 Stop “public-private partnership” deals for hospital buildings and the proposed primary care centres.
 Recruit staff to allow any closed wards and unused beds to be brought into immediate use.
 Restore the frozen vacancies created with the recruitment ban in the public service; these vacancies have disappeared from local authority and hospital personnel lists.
 Immediately end the disgraceful long-running dispute with dentists and chiropodists, either by appointing new public dentists and chiropodists or insisting that existing dentists and chiropodists have at least a proportion of public patients in order to practise.
 End the subcontracting of laboratory testing, cleaning and administrative services to private companies.
 As well as listing the number of people on the waiting-list, hospitals should also list how many times the list is closed in a given period, and for how long it remains closed.
 Oppose the plans of large pharmaceutical companies and pharmacies for opening combined pharmacies and doctors’ clinics. This puts medicine in the hands of corporate business and would certainly lead to bias in prescribing drugs.
 Freeze the cost of the drug repayment scheme.
 Freeze the cost of in-patient charges, and end the charges that many hospitals have introduced for the treatment of out-patients.
 Start a public education campaign to inform people of the advantages of a public system and the need to support the cost of such a system through taxes, also pointing out the costs already being incurred by the public in private insurance and out-patient charges, such as for doctors and consultants and for hospital in-patient charges; all of these are hidden taxes.

Long-term reform demands

 A complete review of the health system, to eliminate waste and to establish the real needs of the population. A complete withdrawal from subsidising private hospitals and clinics and for paying for beds in these hospitals. Because of the shortage of hospital beds and nursing homes the Government would need to allocate emergency capital funding to build the infrastructure and to finance the huge initial increase in a fully comprehensive national insurance scheme or combined PRSI and health levy.
 A free health service for all. This would cover hospital stays, routine check-ups, X-rays, immunisations, dental care, necessary ophthalmic care, nursing homes, social workers, physiotherapists, chiropodists, psychiatric services, community nursing care, and special expenses such as wheelchairs and special beds.
 Immediate implementation of the primary care plan by the Government. There should be free services for seeing the doctor, nurses, physiotherapists, midwives, chiropodists, nutritionists, and social workers. These could in many cases be in the existing community-care buildings, except that they would be staffed at a much higher level. Because of the low population density it is not necessary to build high-volume clinics but smaller local ones. End the tax incentives for doctors operating co-operative out-of-hours services and put the money into the primary-care centres.
 Free prescription medicines, with non-profit pharmacies in the community clinics.
 Provide free public nursing-homes to take long-term sick people and the elderly who are now taking up beds in public hospitals because they have nowhere else to go. End the use of private nursing-homes receiving state funds for capital expenditure and tax incentives and for the use of the nursing home for public paying patients.

Some facts and figures

Countries that have public health insurance spend less relative to gross domestic product (GDP) and less per capita on health. In such countries people live longer, and fewer infants die. A report by the Organisation for Economic Co-operation and Development (OECD) on expenditure on health in twenty-nine countries found that those that had a public health system spent less than those that had not. The median amount of GDP spent on health care of the twenty-nine countries fluctuated between 7.9 and 8.4 per cent for 2000–2003.
     Expenditure on health in the United States for the years 2000–2003 as a proportion of GDP was 13.1, 13.8, 14.6 and 15 per cent, respectively—by far the highest of all countries. This means that private companies, hospitals and specialists are making huge profits while a significant proportion of the population cannot afford treatment at all.
     A study published in the New England Journal of Medicine in 2003 estimated that the cost of administering the American health system was about $300 billion in 1999. A more recent study in the International Journal of Health Services found that in 2003 the administration costs in the American health system ate up approximately $400 billion, or about 25 per cent of total health spending.
     By comparison, national health-care systems incur administrative costs of a few per cent of total health expenditure; according to the study in the New England Journal of Medicine, Canada’s national health insurance system spends only 1.3 per cent on overheads.
     A report published by the OECD, Health at a Glance (2007), shows that in 2005 Ireland had only 2.8 acute hospital beds per 1,000 population, compared with an OECD average of 3.9.

Other facts

29 per cent of people are entitled to free public health. These are holders of medical cards. The range of services they can avail of is declining all the time, and the proportion of people holding medical cards is declining each year (from 39 per cent in 1983). (From a presentation by Maeve-Ann Wren to the Irish Social Policy Association, 2006.)
     “The new data, supplied under the Freedom of Information Act, also shows [that] more than 139,000 patients were on outpatient waiting lists at 24 hospitals across the State either last year or earlier this year. Not all hospitals provided details of their outpatient waiting lists so the true figure for the total numbers on outpatient waiting lists in the State would be significantly higher.” (Irish Times, 31 December 2007.)
     65,000 public patients were treated in private hospitals through the National Treatment Purchase Fund from 2002 to the end of 2006. (HSE report.)
     Ireland has the highest mortality rate for breast cancer in the Western world. (OECD report.) Breastcheck covers only eleven of the twenty-six counties.
     There is still no national screening programme for cervical cancer, eight years after the Government pledged it would be introduced.
     There is no screening programme for prostate cancer.


■ Marie O’Connor, Emergency: Irish Hospitals in Chaos.
■ Maeve-Ann Wren and Prof. Dale Tussing, How Ireland Cares: The Case for Health Care Reform.
■ Presentation by Maeve-Ann Wren to Irish Social Policy Association, at www.ispa.ie/documents/131006mwren.pdf.
■ Report of the National Task Force on Medical Staffing (Hanly Report), 2003, at www.dohc.ie/publications/hanly_report.html.

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